AAP Issues Policy on Home Births

Action Points

The AAP in this policy statement concurred with the statement of the American College of Obstetricians and Gynecologists in afﬁrming that hospitals and birthing centers are the safest settings for birth in the U.S., but also said it respects the right of women to make a medically informed decision about delivery.

The incidence of home birth remains below 1% of all births in the U.S., although the rate of home birth has increased during the past several years for white, non-Hispanic women.

The statement outlines the health care system components that the authors say are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes, and makes a number of recommendations for use when considering planned home birth.

Home deliveries should be attended by at least two caregivers, including one formally trained to conduct full infant resuscitation and newborn evaluation, according to a new policy statement from the American Academy of Pediatrics (AAP).

In addition, mothers and healthcare providers planning a home delivery should pretest their telephone to make sure it is functioning, monitor the weather, and make prior arrangements with a medical facility in case an emergency occurs with the mother or child, wrote the AAP online in Pediatrics.

The statement advised pediatricians to be sensitive to women who consider planned home birthing and provide them with planning information. "Every newborn infant deserves high standard healthcare," wrote the authors, who were led by Kristi Watterberg, MD, of the University of New Mexico in Albuquerque.

However, the statement said, home birth in the U.S. is not "well supported ... Obstacles [to home delivery] are pervasive and systemic and include wide variation in state laws and regulations, lack of appropriately trained and willing providers, and lack of supporting systems to ensure the availability of specialty consultation and timely transport to a hospital."

The statement noted that the academy "concurs with the recent position statement of the [American College of Obstetricians and Gynecologists], affirming that hospitals and birthing centers are the safest settings for birth in the United States, while respecting the right of women to make a medically informed decision about delivery."

While the incidence of home birth remains below 1% in the U.S. overall, the rate of home births among white, non-Hispanic women has been increasing, the authors noted. Nevertheless, "travel times greater than 20 minutes [to a healthcare facility] have been associated with increased risk of adverse neonatal outcomes, including mortality."

"A newborn infant who requires any resuscitation should be monitored frequently during the immediate postnatal period, and infants who receive extensive resuscitation (e.g., positive pressure ventilation for more than 30–60 seconds) should be transferred to a medical facility for close monitoring and evaluation."

Home birth mothers and caregivers also should take any infant with respiratory distress, continued cyanosis, or other signs of illness to a medical facility. At least one attendant should be trained in infant resuscitation according to principles of the Neonatal Resuscitation Program.

"Planned home birth in the United States appears to be associated with a two- to three-fold increase in neonatal mortality or an absolute risk increase of approximately one neonatal death per 1,000 non-anomalous live births," the statement said. "Evidence also suggests that infants born at home in the United States have an increased incidence of low Apgar scores and neonatal seizures."

However, they noted a smaller study of all planned home births attended by midwives in British Columbia, Canada, from 2000 to 2004 that showed no increase in neonatal mortality over planned hospital births attended by midwives or physicians.

According to the AAP, the best candidates for home birth will have:

Absence of preexisting maternal disease or significant disease during the pregnancy

Singleton fetus born 37 to less than 41 weeks of pregnancy

Cephalic presentation

Labor that is spontaneous or induced as an outpatient

A mother who has not been referred from another hospital

Systems needed to support planned home birth include:

Available certified nurse-midwife, certified midwife, or physician practicing in regulated health system

One appropriately trained individual to focus on the newborn

Ready access to consultation

Access to safe and timely transport to a nearby hospital with a preexisting arrangement

The statement also included the following guidance:

Transitional care (first 4–8 hours): The infant should be kept warm during a physical assessment for gestational age, intrauterine growth status, temperature, heart and respiratory rates, skin color, peripheral circulation, respiration, consciousness, and tone, and should be monitored every 30 minutes for 2 hours. Infants thought to be less than 37 weeks' gestation should be transferred to a medical facility.

Monitoring for group B streptococcal disease: Pregnant women should be screened for Strep B colonization at 35 to 37 weeks' gestation, and those who are colonized should receive at least 4 hours of intravenous penicillin, ampicillin, or cefazolin. If the mother shows chorioamnionitis or the infant seems unwell, the infant should be transferred rapidly to a medical facility.

Glucose screening: Infants who seem small or large for gestational age, or whose mothers have diabetes, should be delivered in a hospital or birthing center because of the increased risk of hypoglycemia and other neonatal complications. If hypoglycemia exists despite feeding, the infant should be transferred promptly to a medical facility.

Hepatitis B vaccination: The vaccination is recommended for all medically stable infants with a birth weight greater than 4.4 lbs. (2 kg).

Feeding assessment: Breastfeeding should be evaluated by a trained caregiver, and the mother should be encouraged to keep track of input and output.

Bilirubin screening: Infants whose mothers are Rh negative should have cord blood sent for a Coombs direct antibody test; if the mother's blood type is O, the cord blood may be tested for the infant's blood type and direct antibody test, but it is not required provided that there is appropriate surveillance, risk assessment, and follow-up. All newborn infants should be assessed for risk of hyperbilirubinemia and undergo bilirubin screening between 24 and 48 hours.

Universal newborn screening: Every newborn infant should undergo universal newborn screening, including blood testing, as required by state laws.

Hearing screening: Newborns should be screened by 1 month.

Provision of follow-up care: Home birth caregivers should provide comprehensive documentation and communication to the follow-up care provider.

"All newborn infants should be evaluated by a healthcare professional who is knowledgeable and experienced in pediatrics within 24 hours of birth and subsequently within 48 hours of that first evaluation," the statement said.

All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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